Brain Development and Vulnerability to Addictive Disorders

Transcription

1 Brain Development and Vulnerability to Addictive Disorders Ken Winters, Ph.D. Professor, Department of Psychiatry University of Minnesota Minneapolis, MN USA Western Regional Conference on Problem Gambling Awareness Vancouver, WA April 28, 2012

2 #1 Conclusion The emerging science of brain development suggests that the maturing brain of the adolescent does not give rise to optimal assessment of risk and careful decision making.

3 #2 Conclusion The adolescent developing brain, in conjunction with numerous social, attitudinal and economic factors, reinforce the potential health concerns of youth problem gambling and related addictions, particularly drug abuse.

4 #3 Conclusion Most adults that have an addiction problem began their indulgence during adolescence.

5 1. Background gambling

6 Youth Access to Gambling First generation of youth exposed to ready access and varied gambling venues. Minimum legal age to place a bet varies across states, but many opportunities for youth in the United States and Canada.

7 U.S.: Minimum Legal Age Gambling and the Law, Nelson Rose, Whitier Law School 39 states with a lottery 37 states with 18 as legal age 3 states may switch to states with casinos/slots 20 states with 18 as legal age 4 states may switch to 21

8 U.S.: If you are 16 and want to bet legally, live in... Alabama Delaware Georgia Idaho Iowa Kentucky Maine Maryland Virginia Wisconsin Mississippi Montana New Mexico New York North Carolina North Dakota Pennsylvania Texas Washington

9 percent U.S. Youth Participation in All Forms of Gambling (age 14 21) (Welte et al., 2008) cards office pools lottery sports betting skill games bingo dice games casino all gambling

10 Internet Gambling in America: Another Wave of Gambling Expansion

11 Frequency % Internet Gambling With Money by Gambling Group (Derevensky et al., 2006) Non Gambler Social Gambler At-Risk Gambler Probable Pathological

12 University journalism student Mike Schneider won top prize - $1 million - in the Limit Hold'em PartyPoker.com Million V tournament. Photo by Charlie Knutson, from The Minnesota Daily, March 22, 2006

13 Estimates of Problem Gambling- Lifetime (National Research Council, 1999) Percentage Group Range Median Adult <1-3% 1.5% College 3-11% 5% Adolescent 1-7% 2.9% Estimates based on meta-analysis of surveys conducted (National Research Council, 1999). Problem gambling defined in most studies by the SOGS/SOGS-RA.

14 Clinical Issues: Youth and Treatment Since 1999 in Minnesota: over 9,000 calls to the problem gambling hotline 15 calls from teenagers (< 19 years old) over 3,100 referrals into the treatment system.. 0 referrals of teenagers (< 19 years old)

15 Clinical Issues: Youth and Treatment Since 1999 in Minnesota: over 9,000 calls to the problem gambling hotline 14 calls from teenagers (<19 years) over 3,100 referrals into the treatment system.. 14 referrals of years old

16 Clinical Issues: Youth and Treatment Reasons? Low problem recognition Weak public awareness No youth-specific services Other, more observable problems are viewed as more pressing No or minimal financial losses

17 But there are cases Minnesota High School Football Star; was an honor student and had a football scholarship to a Division I school. Became an habitual blackjack player at the local casino after he turned 18. To finance his habit, he fenced stolen property. Was arrested for the thefts.

18 Do Not Forget Developmental Link of Problem Gambling Adolescent Adult

19 mean age Onset of Gambling Variables and Number of Lifetime Symptoms (Kessler et al., in press) Earlier onset among those 5+ Age Onset No Sym 1-2 Sym 3-4 Sym 5+ Sym Age Onset: F = 15.4, p <.001

20 mean age Onset of Gambling Variables and Number of Lifetime Symptoms (Kessler et al., in press) Age Onset Age Onset Prb NA No Sym 1-2 Sym 3-4 Sym 5+ Sym Age Onset Prb: non sig.

21 Youth Problem Gambling as a Component of Problem Behaviors delinquency gambling sexual behavior Problem Behaviors drug use ADHD male

22 Cross-Sectional Study of Adolescents: Association of Psychosocial Problems and Gambling Involvement (Faregh & Derevensky, under review) Psychosocial problems conduct family emotional cognitive anger Gambling Group

23 Longitudinal Study of Youth: Association of Psychosocial Problems and Future Gambling (Pagani et al., 2009) These variables measured in the kindergarten sample: Impulsivity Emotional distress Family functioning Maternal education Parental gambling Sex Measured gambling behavior when they were sixth graders. Pagani et al., 2009

24 1. Background drug abuse

25 Evidence from Epidemiological Studies Drug use starts early and peaks in the teen years

26 Prevalence of Past-Year DSM-IV Alcohol Dependence: United States, (Grant, B.F., et al., Drug and Alcohol Dependence, 74, , 2004) %

27 Percentages of Past Year Alcohol Use Disorder (Abuse or Dependence) Among Adults Aged 21 or Older, by Age of First Use (SAMHSA, 2005) Fewer Problems in Those Who Start Later % <12 yrs yrs yrs yrs 21+ yrs Age Started Drinking

28 Childhood Self-Control as a Predictor of Adult Substance Use Dependence (Moffitt et al., in press) Outcomes were converted to Z-Scores and childhood self-control is represented in quintiles.

29 1. Background 2. Neurodevelopment

30 Adolescence is a period of profound brain maturation. We thought brain development was complete by adolescence We now know maturation is not complete until about age 25!!!

31 An Immature Brain = Less Brakes on the Go System

32 Brain Development Volume Metabolism Myelination Blood Flow Receptors Synaptic Refinement Adolescence RATE OF CHANGE Prenatal Post-birth Age Tapert & Schweinsburg (2005)

33 Construction Ahead When the pruning is complete, the brain is faster and more efficient. But during the pruning process, the brain s activity is not the same compared to a mature brain.

34 Maturation Occurs from Back to Front of the Brain Images of Brain Development in Healthy Youth (Ages 5 20) Earlier: Motor Coordination Emotion Motivation Later: Judgment Blue represents maturing of brain areas Source: PHAS USA 2004 May 25; 101(21): Epub 2004 May 17.

35 Implications of Brain Development for Adolescent Behavior Preference for. 1. physical activity 2. high excitement and rewarding activities 3. activities with peers that trigger high intensity/arousal 4. novelty Less than optimal.. 5. control of emotional arousal 6. consideration of negative conseq. Greater tendency to 7. be attentive to social information 8. take risks and show impulsiveness

36 Risk-Taking Based on science of brain development, a modern view of risk taking in adolescence is normative; important to development evolutionarily adaptive is due primarily to emotional and contextual, not cognitive, factors

37 Implications of Brain Development for Adolescent Behavior Preference for. 1. physical activity 2. high excitement and rewarding activities 3. activities with peers that trigger high intensity/arousal 4. novelty Less than optimal.. 5. control of emotional arousal 6. consideration of negative conseq. Greater tendency to 7. be attentive to social information 8. take risks and show impulsiveness

38 Cautions about what to infer regarding the Immature Brain

39 An Immature Brain = Low Brain Power

40 Taking the Same Ability Test at Age 11 & Age 80: Scottish Mental Survey MHT IQ age 80 years MHT IQ age 11 years Deary et al. (2004) Journal of Personality and Social Psychology, 86,

41 An Immature Brain = Absence of Understanding Risk

42 Risk Assessment Adolescents understand dangers and consequences associated with risk. But adolescents tend to be more sensitive to contextual factors when applying risk knowledge to decision making.

43 1. Background 3. Neurodevelopment and gambling 2. Neurodevelopment youth in general ADHD youth

44 Does normal brain development contribute to adolescent susceptibility to gambling? INDIRECT SUPPORT: 1. > risk taking (particularly in groups) (gambling?) 2. > propensity toward low effort - high excitement activities (gambling?) 3. < capacity for good judgment & weighing consequences (gambling?) 4. > sensitivity to novel stimuli (gambling?)

45 Are youth with ADHD at heightened risk? These youth suffer from problems with judgment and self-regulation, believed to be linked to pre-frontal cortex deficits. ADHD, as defined by DSM-IV, is a constellation of symptoms related to Inattention Hyperactivity Prevalence: about 3% boys > girls

46 ADHD as heightened risk Growing evidence that ADHD. is a dysfunction in the brain s regulatory systems that manifests as a deficit in behavioral dysregulation, this dysregulation is mediated by deficits in the pre-frontal cortex, and these deficits in pre-frontal cortex contribute to a disorder likely related to self-regulation - drug abuse (Barkley, 1997; Martin, Earlywine, Blackson et al., 1994)

47 Link of ADHD and drug abuse Among children with ADHD (some with CD also), compared to comparison... Variable Odds Ratio SUD Elevated alcohol use Elevated marijuana use Elevated tobacco use adapted Molina et al., in press

48 Supportive Data The ADHD - PG connection: adult data PG non-pg psych. Rate of childhood ADHD 15-36% 4-8% (sig.) (Carlton et al., 1987; Rugle & Melamed, 1993)

49 Supportive Data The ADHD - PG connection: adult data PG normals Rate of adulthood ADHD 21% <1% (sig.) (Specker et al., 1995)

50 Suggestive Data The ADHD - PG connection: adolescent and young adult data

51 Association of Adolescent Gambling and Dimensional Measures of Hyperactivity and ADHD (Derevensky et al., 2007) Gambling Groups Non gambler Social gambler At-risk gambler Probable pathological gambler CASS-L Subscales 1 N M M M M Hyperactivity boys girls ADHD Index boys girls Note: All one-way ANOVA s significant, p <.01; nearly all SNK sig.: NG<SG<AR<PPG 1 Conners-Wells Adolescent Self-Report Scale: Long Version (Conners & Wells, 1997) Derevensky JL, Pratt LM, Hardoon KK, Gupta R. (2007). Gambling problems and features of attention deficit hyperactivity disorder among children and adolescents. Journal of Addiction Medicine, 1,

52 Association of Adolescent Gambling and Probable ADHD Status 1 (Derevensky et al., 2007) ADHD + ADHD - (n = 231) (n =2105) Groups (N = 2336) % % Nongamblers (30%) 6 94 Social (54%) 8 92 At-Risk (8%) Prob. Path. (5%) Based on the ADHD Index (Conners & Wells, 1997) X 2 = 113, p <.001 Derevensky JL, Pratt LM, Hardoon KK, Gupta R. (2007). Gambling problems and features of attention deficit hyperactivity disorder among children and adolescents. Journal of Addiction Medicine, 1,

53 Minnesota ADHD Study (Breyer, Winters, August, & Realmuto, 2009) ADHD-persis ADHD-desist Controls sig. n Gender (% male) Mean age at last follow-up % grad high school or current (p <.05) Mean IQ (KBIT) (baseline) Mean SES (baseline) * Attrition: ADHD, 87% of eligible; Controls, 91% of eligible. Ethnicity: 88% Caucasian * Hollingshead, 1975, (occupation code x 5) x (education code x 3); Range 17-66

54 Minnesota ADHD Study (Breyer, Winters, August, & Realmuto, 2009) ADHD-persis ADHD-desist Controls sig. any gambling (%) PG among all 1 (%) (p <.05) PG among gamb 1 (%) (p <.01) SOGS-RA score (mean) (p <.05) Count games played (mean) PG = SOGS-RA 2+

55 1. Background 3. Neurodevelopment and alcohol abuse 2. Neurodevelopment

56 Adolescents may have different sensitivity to alcohol than adults Adolescent rats are less sensitive to the sedative and motor impairment effects of intoxication. Adolescent rats are more sensitive to the social disinhibition effects of alcohol.

57 The Water Maze Test Hidden Slide courtesy Sion Kim Harris, Ph.D. Saline vs alcohol Measures -Swimming speed -Time to find platform

58 Adolescents may have different sensitivity to alcohol than adults Adolescent rats are less sensitive to the sedative and motor impairment effects of intoxication. Adolescent rats are more sensitive to the social disinhibition effects of alcohol.

59 Wanna look for some cheese with me? Sure!

60 1. Background 4. Summary 3. Neurodevelopment and gambling 2. Neurodevelopment

61 Summary Adolescence is an extended period of transition from reliance on adults to independence Normal adolescence is characterized by. increase in conflicts with family members desire to be with one s friends resistance to messages from authority irritability risk taking proclamations of sheer boredom

62 Summary The brain undergoes a considerable amount of development during the teen years. Gray Gray Matter Matter Maturation, Age 4-21 (Gogtay Gogtay et al., et 2004) al., 2004 The last area to mature is the prefrontal cortex region; involved in planning, decision making and impulse control.

63 Summary Gray Gray Matter Matter Maturation, Age 4-21 (Gogtay Gogtay et al., et 2004) al., 2004 reward incentives > perception of consequences

64 Summary Evidence is accumulating that youth gambling occurs on a continuum most youth gamble, yet do so infrequently the prevalence of problem gambling is noteworthy

65 Summary Possible links between neurodevelopment and addictive behaviors Problem Gambling No Sym 1-2 Sym 3-4 Sym 5+ Sym Age Onset Alcohol Use Disorder <12 yrs yrs yrs yrs 21+ yrs

66 Summary Clinical Implications PG Field Screen target groups for gambling Drug-abusing youth Youth with ADHD

67 Lie/Bet Screen (Johnson et al., 1997) 2-question version of the DSM-IV criteria: 1. Have you ever had to lie to people important to you about how much you gambled? 2. Ever felt the need to bet more and more money? Score of 1+ is a red flag.

68 Measures SOGS-RA Winters, Stinchfield, & Fulkerson, 1989/1993 Adapted from the SOGS 12 yes/no items Prior 12-months time frame Psychometrics favorable Cut score for Problem Gambling not empirically established

69 Measures DSM-IV-J Fisher, 1992 Reflect 9 dimensions of DSM-IV 12 yes/no items Prior 12-months time frame Psychometrics favorable Cut score for Pathological Gambling not empirically established

70 Summary Clinical Implications PG Field Treatment issues Drug-abusers raise insights that gambling is another source of intoxication educate that gambling may be a source of relapse (gambling urges can be powerful)

71 Summary Clinical Implications PG Field Treatment issues Youth with ADHD raise insights that gambling is a source of excitement teach limits, if the person gambles

72 Working with Parents P = Promote activities that capitalize on the strengths of the developing brain. A = Assist children with challenges that require planning. R = Reinforce their seeking advice from adults; teach decision making. E = Encourage lifestyle that promotes good brain development. N = Never underestimate the impact of a parent being a good role model. T = Tolerate the oops behaviors due to an immature brain.

73 THANK YOU!